Interim Designation of Agent To Receive Notice Of Claimed Infringement
Full Legal Name of Internet Service Provider is: [Insert Full Legal Name Here]
Alternative Names of Service Provider (including all names under which the service provider is doing business): [Insert all fictitious names, assumed names, and other names under which you are doing business here] Address of Service Provider: [Insert business address of Service Provider here] Name of Agent Designated to Receive Notification of Claimed Infringement: [Insert Name of Designated Agent Here] Full Address of Designated Agent To Which Notification Should Be Sent (note that a Post Office Box or similar designation is not acceptable except where it is the only address that can be used in the geographic locations): [Insert Full Address of Designated Agent Here] Telephone Number of Designated Agent: [Insert Telephone Number of Designated Agent Here]
Facsimile Number of Designated Agent: [Insert Fax Number of Designated Agent Here]
Email Address of Designated Agent: [Insert Email Address of Designated Agent Here]
_________________________________________ Signature of Officer or Representative of the Designating Service Provider Date: _____________________________ _________________________________________ Typed or printed name and title:
NOTE: This Amended Interim Designation Must Be Accompanied by a $20.00 Filing Fee Made Payable To the Register of Copyrights.